National Center for Education in Maternal and Child Health

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July 28, 2000

1. Study Finds Association Between Early Postpartum Discharge and Infant Mortality

2. Report Indicates That Pregnant Women May Need to Limit Intake of Fish and Seafood

3. Researchers Find Molecular Link Between SIDS and Rare Heart Disorder

4. Article States That HIV-Infected Adults Need Family-Centered Support

5. Research Examines Mothers' Reactions to False-Positive Hearing Screening Results

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1. STUDY FINDS ASSOCIATION BETWEEN EARLY POSTPARTUM DISCHARGE AND INFANT MORTALITY

Newborns discharged within 30 hours of birth are at increased risk of death within the first year of life, concludes a study in the August issue of Obstetrics & Gynecology. Researchers assessed risk of death within the first year of life after early discharge (less than 30 hours after birth) compared with later discharge (30 to 78 hours). The study used linked birth certificates, death certificates, and hospital discharge records that covered 47,879 births in Washington State in 1989 and 1990. The authors state that to their knowledge "this is the first study to establish a statistically significant association between early postpartum discharge and newborn mortality."

Study results include the following:

• Newborns discharged early were more likely to die within 28 days of birth, between 29 days and 1 year, and any time within the first year of life than newborns sent home later.
• Newborns discharged early were more likely to die of heart-related problems and infections within 1 year of birth than newborns discharged later.
• Comparison of average maternal characteristics for the groups (i.e., marital status, Medicaid status) indicated that newborns discharged early had significantly lower socioeconomic status than newborns with longer stays.
• Newborns discharged early were significantly healthier on average, and their mothers were significantly more likely to be multiparous--perhaps because second and subsequent vaginal deliveries are often easier than first.
• Of the 155 deaths in the sample, 103 (66.5%) were attributed to sudden infant death syndrome (SIDS), 14 (9%) were caused by heart-related conditions, and 8 (5.2%) were caused by infection. Accidents and injuries caused 13 deaths, and other deaths were attributed to nervous system conditions, respiratory conditions, gastrointestinal conditions, and other conditions.
• The authors did not evaluate the cost of requiring longer hospital stays. They did, however, estimate that about 1,400 infants in the early-discharge group would have had to be moved to the late-discharge category to prevent one infant death.

The article notes that the incidence of SIDS in the sample was 0.22%, higher than the 0.14% national rate for infants in 1989. It also notes a study limitation: since time of discharge was not included in the data set, length of stay could not be calculated to the hour.

In assessing the generalizability of their findings, the authors state that Washington has a lower percentage of teen births and racial and ethnic minority births than the national average. However, they state that "if an increase in length of stay has a disproportionately beneficial effect on minorities or teen mothers (for example, teen mothers may have a greater need than older mothers to receive instruction on caring for their newborns), the mortality effects of early discharge . . . might understate those effects nationally." They also state that their research predates the mandating of length-of-stay laws, which is a strength, and that it predates the American Academy of Pediatrics' Back to Sleep campaign, which was designed to prevent SIDS. Referring to the campaign, they state that "in the presence of such a concerted educational effort, we hypothesize that longer postpartum stays would decrease mortality even further than what was seen in our sample."

Malkin JD et al. 2000. Infant mortality and early discharge. Obstetrics & Gynecology 96(2):183-188.

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2. REPORT INDICATES THAT PREGNANT WOMEN MAY NEED TO LIMIT INTAKE OF FISH AND SEAFOOD

Children of women who consume large amounts of fish and seafood during pregnancy may be at special risk for neurological problems, according to a press release on a National Academies' National Research Council report. The report responds to a congressional request concerning appropriate exposure limits for methylmercury. It concludes that the US Environmental Protection Agency's (EPA) mercury guideline is justifiable, but it states that pregnant women's consumption of fish and seafood may adversely affect their fetuses.

Noting that fish and seafood are the main source of methylmercury in the human diet, the press release states that fetuses are particularly vulnerable to its effects because of their rapid brain development. The release explains that mercury exists naturally in the environment and finds its way into the air through both natural processes and human activities, but that power plants that burn fossil fuels generate the most mercury emissions. When mercury is deposited into water, fish accumulate it, and it is then ingested by humans who consume the fish. The Washington Post notes that "long-lived fish that feed on other fish--a group that includes swordfish, shark, tuna and king mackerel--accumulate the highest levels and pose the greatest risk to humans who eat them." According to the Post, the EPA estimates that 7% of US women exceed the EPA recommended limit for methylmercury exposure (0.1 micrograms per kilogram of body weight per day), and that, by that estimate, 60,000 babies born each year are at risk for toxic exposure.

The chair of the committee that wrote the National Academies' National Research Council report states that "trends in methylmercury exposure, including regional differences, should be analyzed, as should subpopulations whose diets are high in fish and seafood. And we need to better understand how this chemical affects brain development in fetuses and children."

The National Academies. 2000, July. EPA's methylmercury guideline is scientifically justifiable for protecting most Americans, but some may be at risk. Press release available at <http://www4.nationalacademies.org/news.nsf/isbn/0309071402?OpenDocument>. The full report is available at <http://www.nap.edu/books/0309071402/html/>.

Thompson D, Squires S. 2000, July 25. Intake. The Washington Post Online, p. Z06.

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3. RESEARCHERS FIND MOLECULAR LINK BETWEEN SIDS AND RARE HEART DISORDER

Sudden infant death syndrome (SIDS) may be linked to a rare heart disorder called long-QT syndrome, according to a study by researchers from Italy published in this week's New England Journal of Medicine and reported by the New York Times. The authors estimate that long-QT syndrome may account for 25% to 30% of SIDS cases and suggest that all infants be given electrocardiograms to screen for the heart condition--a suggestion criticized by American experts as impractical because it result in many infants with ambiguous test results receiving unneeded treatment and also because it would be so expensive.

According to the Times article, in 1998 the authors reported the results of a 19-year prospective study of more than 33,034 infants who had electrocardiograms at birth. They found that 50% of the 24 infants who died of SIDS had long-QT syndrome. But the majority of infants with long-QT syndrome remained healthy. No genetic testing was done. At that time, the researchers did not recommend electrocardiograms for all infants, but they did recommend them for infants at high risk because of a family history of SIDS or long-QT syndrome, and for those who had nearly died from a heart or breathing problem resembling SIDS.

Now, however, the authors claim that family history cannot be used to identify infants at high risk for heart disorders. They came to this conclusion after studying the case of an infant who nearly died of SIDS and whose electrocardiogram revealed long-QT syndrome, but whose parents did not have the genetic disorder. In this study, the authors suggest that many infants could be saved if those identified by an electrocardiogram as having long-QT syndrome were given preventive treatment against SIDS soon after birth.

Grady D. 2000, July 27. Researchers link SIDS to disorder of the heart. The New York Times on the Web. Available, after site registration, at <http://www.nytimes.com/library/national/science/health/072700hth-infant-sids.html>.

Schwartz PJ et al. 2000. Brief report: A molecular link between the sudden infant death syndrome and the long-QT syndrome. The New England Journal of Medicine 343(4):262-267.

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4. ARTICLE STATES THAT HIV-INFECTED ADULTS NEED FAMILY-CENTERED SUPPORT

A large proportion of HIV-infected adults have children under the age of 18, and these adults should have access to family-centered support services, according to a study published in the American Journal of Public Health. Twenty-eight percent of infected adults surveyed in the national HIV Cost and Services Utilization Study (conducted in 1996 and early 1997) had at least one child under the age of 18. The authors state that the actual percentage is even higher, since the study excluded infected parents with no health care and those who received care in prisons, military facilities, and emergency rooms.

The study was based on a multiple-stage national probability sampling of adults with known HIV in both metropolitan and rural areas. Among the study's findings are the following:

• 53% of the respondents with children had more than one child, 29% had two, 14% had three, and 10% had four or more.
• Among the respondents with children, 16% had children ages 0 to 2; 24% had children ages 3 to 5; 59% had children ages 6 to 12; and 45% had children ages 13 to 17.
• 12% of women and 2% of men had conceived a child after being diagnosed with HIV (i.e., the child was born 10 or more months after diagnosis).
• 10% of women and 1% of men had a child who was born after diagnosis but probably conceived before.
• Among the children of respondents, 52% lived with the respondent, and 28% lived with their other parent, for a total of 80% living with at least one parent. The remaining children lived with a grandmother, another relative, or an unrelated foster or adoptive parent, or in another setting such as a group home.

Many HIV-infected parents in the study were at a relatively advanced stage of illness, which likely affected their ability to care for their children. Sixty percent of parents living with their children had symptomatic HIV, 30% had AIDS, and 21% had been hospitalized during the previous 6 months. The data also showed that 17% lacked health insurance, 19% put off going to the doctor because they were too sick, and 20% had needed to find a place to live in the previous 6 months.

The authors state that "because it is reasonable to consider the minor children of HIV-infected parents as part of the HIV-affected population, this indicates a much larger disease burden than has been commonly recognized." They conclude that "any planning for the future of the epidemic will need to consider the impact on parents of having responsibility for children and the impact on children of having parents with a chronic, stigmatizing, and potentially fatal condition." Systems of care that address HIV-affected families' needs (including medical care, supervision, counseling services, child-care provisions, and financial support) will best serve those families affected by the HIV/AIDS epidemic.

Schuster MA et al. 2000. HIV-infected parents and their children in the United States. American Journal of Public Health 90(7):1074-1081.

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5. RESEARCH EXAMINES MOTHERS' REACTIONS TO FALSE-POSITIVE HEARING SCREENING RESULTS

Lasting maternal anxiety from their newborns' false-positive hearing results seems uncommon, according to research findings published in Pediatrics. Noting that critics of universal newborn hearing screening (UNHS) point to high false-positive rates as cause for concern, the authors examined one program's false-positive rates and explored the effect of these rates on maternal anxiety. They studied data from 5,010 infants screened as part of a UNHS program in North Carolina and interviewed the newborns' mothers using a structured telephone survey.

The study's findings include the following:

• Hearing loss in newborns not in neonatal intensive care units occurred at a rate of 1.8/1,000.
• A false-positive rate of 1.9% occurred during the first stage--screening before newborn discharge. The authors attribute this relatively low rate to the fact that 51% of newborns who failed the initial screen were rescreened before hospital discharge.
• If all newborns who failed the initial screen had been rescreened before hospital discharge, the false-positive rate would have approached .5%.
• Only 9% of mothers whose newborns' results indicated hearing loss said that they "treated their child differently" before outpatient rescreening, and only 14% reported any lasting anxiety after their child passed the outpatient repeat screen.
• 90% of mothers believed that UNHS was a good idea.

The authors concluded that rescreening all newborns before hospital discharge would reduce to less than 1% the false-positive rate of UNHS using automated auditory brainstem response. Study limitations include a lack of information about the number of false-negative results, a small sample size, and the fact that the mothers in the study sample may have been older and may have had more formal education than average. The authors state that "lasting anxiety from false-positive hearing screens seems to be uncommon. Despite this reassuring finding, rescreening all eligible newborns before hospital discharge and clear communication with families are necessary to make this screening tool even better."

Clemens CJ, Davis SA, Bailey AB. 2000. The false-positive in universal newborn hearing screening. Pediatrics Electronics Pages 106(1):e7. Available at <http://www.pediatrics.org/cgi/content/full/106/1/e7>.

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